ON
BEING
A
DOCTOR
Core Curriculum We all have had one patient we never forget. For me that patient was Helen. I was in my fourth month of internship and, like many of my colleagues, had doubts concerning my career choice of internal medicine. It seemed my patients never improved and were bouncing in and out of the hospital on a monthly basis. Yes, there was the occasional young patient with pneumonia who made a complete recovery, but it seemed that the patients I was most familiar with, those with chronic lung disease or congestive heart failure or diabetes or cancer, would often show only modest improvement, an improvement that seemed to last for less time with each successive hospitalization. I was chronically tired and irritable, and I began to wonder what the reason for this futility might be. It was at this point that Helen came into my life. It was my first day on the oncology service, a rotation I had been dreading for weeks. Helen was my first assigned patient. She had been fighting a long, arduous battle against breast cancer, with multiple recurrences and repeated courses of chemotherapy. She came to the emergency room with fever, hemolytic anemia, fluctuating neurologic signs, and severe thrombocytopenia. She had thrombotic thrombocytopenic purpura. Because my service wasn't very busy, I found myself spending a great deal of time with Helen. She had recently moved to our locale after the death of her husband and had no friends or relatives in the area, no one to visit her. Helen was an exceptionally intelligent, courageous human being and always maintained her sense of humor. She understood her disease and frequently asked direct, specific questions about her prognosis, questions I found difficult to answer. We discussed her "code status" often, usually at her request. She was determined to live her life as fully as possible for as long as possible, despite her deteriorating condition. The weeks went by. Helen and I came to understand each other. If it was a quiet night on call, I would stop by her room to play cards. I asked about her past, learned about a previous brush with death after an automobile accident in which her son was killed, her long career as a college professor, and the sudden and tragic recent death of her husband. I began to respect Helen, to admire her, and, even more, to like her. Helen's condition worsened. She became confused. I could not raise her platelet count. One day in the midst of this, Helen begged me not to let her die. I felt helpless, guilty, knowing there was absolutely nothing I could do. The next day she asked her nurse to have me stop by again. She had changed her mind. She had had
enough; she did not want her life prolonged in any way, should she continue to grow worse. The next day I confirmed her decision and reassured her that it was the right decision considering her stage of the disease. It was the first time I had seen Helen cry. Three nights later, on call, I was summoned to Helen's room. She was short of breath, diaphoretic, and coughing. Each cough produced dark clots. Her chest x-ray suggested massive pulmonary hemorrhage, and I knew that Helen's time had come. I sat at the bedside holding her hand. She looked remarkably calm and accepting. She turned slowly to her nightstand and removed an envelope from the drawer. "Read it later," she said as she smiled weakly, handing it to me. Over the next hour, still holding her hand, I watched as she drifted in and out of consciousness and eventually stopped breathing. I pronounced her dead. The entire scene seemed to me strangely surrealistic. I returned to the on-call room and opened the envelope. Her letter thanked me for my care and, more important, for my friendship, for caring about her. She was especially grateful for the kindness, respect, and friendship she had felt from me. I realized that that way of treating her was the only aspect of her care that had come with little effort and also the only aspect of her care never mentioned or encouraged on my daily teaching rounds. I saved the letter, carried it in my pockets for weeks. It was the first time I cried over the death of a patient. I've never forgotten Helen. She has changed the way I view patients. From her I learned that curing a disease is not always the most important aspect of the doctorpatient relationship. Patients visit their doctors for many reasons, sometimes for emotional support or kindness, for empathy and for openness, far more therapeutic than medications. Few things are more edifying than a patient who, despite having a deteriorating medical condition, seems to enjoy coming to the office. Since Helen, I treat all my patients with trust and respect, or try to, and perhaps more importantly, I treat them as equal human beings. And on those days when practice is especially difficult, when there seems no reward, I read Helen's letter again and remember that it is possible, no matter what the outcome, to make a difference in the life of a patient. Jeffrey A. Katt, MD Milwaukee Medical Clinic Milwaukee, WI 53217 Annals of Internal Medicine. 1992;117:607.
© 1992 American College of Physicians Downloaded from https://annals.org by Tulane University user on 01/18/2019
607
BEING
A
DOCTOR
Core Curriculum We all have had one patient we never forget. For me that patient was Helen. I was in my fourth month of internship and, like many of my colleagues, had doubts concerning my career choice of internal medicine. It seemed my patients never improved and were bouncing in and out of the hospital on a monthly basis. Yes, there was the occasional young patient with pneumonia who made a complete recovery, but it seemed that the patients I was most familiar with, those with chronic lung disease or congestive heart failure or diabetes or cancer, would often show only modest improvement, an improvement that seemed to last for less time with each successive hospitalization. I was chronically tired and irritable, and I began to wonder what the reason for this futility might be. It was at this point that Helen came into my life. It was my first day on the oncology service, a rotation I had been dreading for weeks. Helen was my first assigned patient. She had been fighting a long, arduous battle against breast cancer, with multiple recurrences and repeated courses of chemotherapy. She came to the emergency room with fever, hemolytic anemia, fluctuating neurologic signs, and severe thrombocytopenia. She had thrombotic thrombocytopenic purpura. Because my service wasn't very busy, I found myself spending a great deal of time with Helen. She had recently moved to our locale after the death of her husband and had no friends or relatives in the area, no one to visit her. Helen was an exceptionally intelligent, courageous human being and always maintained her sense of humor. She understood her disease and frequently asked direct, specific questions about her prognosis, questions I found difficult to answer. We discussed her "code status" often, usually at her request. She was determined to live her life as fully as possible for as long as possible, despite her deteriorating condition. The weeks went by. Helen and I came to understand each other. If it was a quiet night on call, I would stop by her room to play cards. I asked about her past, learned about a previous brush with death after an automobile accident in which her son was killed, her long career as a college professor, and the sudden and tragic recent death of her husband. I began to respect Helen, to admire her, and, even more, to like her. Helen's condition worsened. She became confused. I could not raise her platelet count. One day in the midst of this, Helen begged me not to let her die. I felt helpless, guilty, knowing there was absolutely nothing I could do. The next day she asked her nurse to have me stop by again. She had changed her mind. She had had
enough; she did not want her life prolonged in any way, should she continue to grow worse. The next day I confirmed her decision and reassured her that it was the right decision considering her stage of the disease. It was the first time I had seen Helen cry. Three nights later, on call, I was summoned to Helen's room. She was short of breath, diaphoretic, and coughing. Each cough produced dark clots. Her chest x-ray suggested massive pulmonary hemorrhage, and I knew that Helen's time had come. I sat at the bedside holding her hand. She looked remarkably calm and accepting. She turned slowly to her nightstand and removed an envelope from the drawer. "Read it later," she said as she smiled weakly, handing it to me. Over the next hour, still holding her hand, I watched as she drifted in and out of consciousness and eventually stopped breathing. I pronounced her dead. The entire scene seemed to me strangely surrealistic. I returned to the on-call room and opened the envelope. Her letter thanked me for my care and, more important, for my friendship, for caring about her. She was especially grateful for the kindness, respect, and friendship she had felt from me. I realized that that way of treating her was the only aspect of her care that had come with little effort and also the only aspect of her care never mentioned or encouraged on my daily teaching rounds. I saved the letter, carried it in my pockets for weeks. It was the first time I cried over the death of a patient. I've never forgotten Helen. She has changed the way I view patients. From her I learned that curing a disease is not always the most important aspect of the doctorpatient relationship. Patients visit their doctors for many reasons, sometimes for emotional support or kindness, for empathy and for openness, far more therapeutic than medications. Few things are more edifying than a patient who, despite having a deteriorating medical condition, seems to enjoy coming to the office. Since Helen, I treat all my patients with trust and respect, or try to, and perhaps more importantly, I treat them as equal human beings. And on those days when practice is especially difficult, when there seems no reward, I read Helen's letter again and remember that it is possible, no matter what the outcome, to make a difference in the life of a patient. Jeffrey A. Katt, MD Milwaukee Medical Clinic Milwaukee, WI 53217 Annals of Internal Medicine. 1992;117:607.
© 1992 American College of Physicians Downloaded from https://annals.org by Tulane University user on 01/18/2019
607
